Program Registration Form

Thank you for choosing our programs! We are thrilled to be a part of your journey! Let's get to know you! Please complete one (1) Registration Form for each participant. All responses are personal and confidential and will not be shared with a third-party.

Section 1 | Participant Information

Program Selection *

Select a program

Brown Girls Climbing

Homeschool Rocks! Climbing Course

Our Community Group

Black Climbers Collective

Queer Climbing Coalition

Moms Rock!

Participant's Name *

Participant's Name

First Name

Last Name

Preferred Name

Gender *

DOB *

DOB

MM

DD

YYYY

Mailing Address *

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Email Address *

Contact Phone Number

Section 2 | Parent/Guardian Information

Parent/Guardian Name

Parent/Guardian Name

Please complete for participants 17 years old or younger.

First Name

Last Name

Mailing Address

Mailing Address

complete if different from participant

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary phone

Primary phone

(###)

###

####

Secondary phone

Secondary phone

(###)

###

####

Parent/Guardian

Parent/Guardian

Please complete information for additional parent/guardian/family

First Name

Last Name

Primary Phone

Primary Phone

(###)

###

####

Secondary Phone

Secondary Phone

(###)

###

####

Emergency Contact *

Emergency Contact

List an emergency contact

First Name

Last Name

Emergency Contact *

Emergency Contact

List an emergency contact

First Name

Last Name

Section 3 Health Information

Please take a moment to complete these important questions.

Previous Injuries *

None

Neck

Back

Shoulders

Extremities

Allergies *

None

Food

Environmental

Medical

Dietary Restrictions *

None

Gluten Free

Dairy Free

Nut Free

Vegetarian

Vega

Motor Challenges

Does participant have any challenges with motor, coordination, movement, strength, stability or muscle control?

Fine Motor Skills

Gross Motor Skills

Neuromuscular

Spinal Muscular

Prosthetic

Chair bound

Visual Impairments *

None

Wears glasses/contact for corrective vision

Color Blind

Depth Limitations

Partial Blindness

Blind

Personality *

Introvert

Extrovert

Cautious

Risk-Taker

Assertive

Academic

Competitive

Artistic

Feel free to tell us more!!

Section 4 Medical Information

Please complete insurance information

Insurance Company *

Policy or Certificate No. *

Insurance Address *

Insurance Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Phone *

Insurance Phone

(###)

###

####

Primary Care Physician (PCP) *

PCP phone *

PCP phone

(###)

###

####

Preferred Hospital/ER *

Thank you for taking the time to complete this form!

Questions or Comments?

Thank you for registering. We have received your information and will be in touch within 24 hours.